At athenahealth's annual user conference, CEO Jonathan Bush said that membership in the EHR Association (EHRA) put his company at odds with its business model. While the EHRA comprises mostly vendors whose customers host their own systems, athenahealth hosts a suite of cloud applications on behalf of its customers. It also aggregates and analyzes payer reimbursement data in order to assist customers in maximizing payments. It felt at times, Bush said, as if EHRA was advocating for federal legislation favoring "shrinkwrapped software makers" at the expense of cloud vendors.

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The very nicest dinosaur is still a dinosaur ... we are a different species.

Jonathan Bush, CEO, athenahealth

"The things that are important to them are, in many ways, the opposite of what we think society needs," said Bush in an interview with SearchHealthIT. That includes EHR upgrade paths. As a cloud vendor, athenahealth frequently updates its software, while non-cloud vendors might take months or years to release new versions. "That is the difference with software in the cloud. I don't want to put money into making laws that forbid flexibility ... that's the opposite of what we want."

Behind the scenes, Dan Haley, vice president of government affairs, was the main advocate for athenahealth dropping out of EHRA. He said that he found himself on Capitol Hill promoting positions that at times went against the EHRA's, which created confusion. He'd be saying one thing and the EHRA -- which included athenahealth's logo in its materials -- would be saying another. It happened enough times, Haley said, that there wasn't enough upside to staying in the group.

"We were repeatedly getting the quizzical look," from legislative staffers and federal advisory committee members, Haley said. "It's nice to find a staffer who actually has done some reading on the issue you're talking about and when we'd find these staffers they'd say, 'Aren't you members of the EHRA? Because I'm pretty sure they said...the opposite.'

"So we'd be obligated to back up and instead of explaining our own positions -- and time is valuable with these people, the smart ones -- we'd end up having not only to explain our position but also explain why we disagreed with our trade association. In the best case, it made for a good conversation. In the worst, it would undermine our credibility."

This had happened on numerous occasions including health data interoperability initiatives. While the trade association would push back at proposed standards and timetables and say as a group, "It's too high, too fast, too much," athenahealth, Haley said, wanted to move faster. Pushing back against ONC and CMS as hard as the EHRA did, athenahealth felt amounted to undermining well-intentioned federal health IT initiatives. In effect, wasting both federal dollars and private healthcare resources by advocating lower standards and delaying technology implementation deadlines.

The last straw that prompted athenahealth to leave the EHRA involved policy surrounding meaningful use hardship exceptions. Athenahealth wanted CMS to reveal which vendors weren't ready for meaningful use stage 2, in a similar fashion to how CMS releases data on which vendors providers use to successfully attest. Physicians and hospitals whose software vendors were late in securing ONC certification for meaningful use can apply for hardship exceptions in order to keep receiving EHR Incentive Program checks, avoiding Medicare and Medicaid penalties if their vendors delivered upgrades too late for the healthcare providers to attest to meaningful use.

CMS publicly revealing which physicians and hospitals received the exceptions -- and what EHR they were using -- would expose the vendors who weren't ready. Haley said athenahealth has a high success rate for customer meaningful use attestation. It would be an advantage to show which competitors were so slow to get EHRs certified that it caused CMS to issue hardship exceptions.

The EHRA denies they advocated keeping this data sealed. According to a statement released through spokesperson Elizabeth West, the group said it doesn't oppose CMS releasing "data regarding meaningful use transparency within the hardship exception process." It characterized athenahealth's contention that the group wanted to cover for EHRA members who were late delivering ONC-certified upgrades as inaccurate.

"Ultimately, the Association is successful because we have the support and collaboration of companies that provide and express a range of viewpoints," the EHRA said in its statement. "...Transparency, accuracy, and balanced representation of all members' interests are core values of the EHRA, and we strive to reflect just that in the Association's leadership and workgroup composition, as well as in our policy positions."

For now, those policy positions will not include representation from athenahealth and its 53,000 customers. Bush, however, wanted to make it clear that his company's dropping out of the EHRA wasn't a snub at his fellow EHR vendor CEOs, but purely a business move.

"It's hard. I like to be liked," Bush said. "These people are giants, these are people I want the approval of. [Cerner Corp. CEO] Neal Patterson, [Epic Systems Corp. CEO] Judy Faulkner, [Epic president] Carl Dvorak, they all are important, inspiring people to me. So I don't like the idea of upsetting them. But the very nicest dinosaur is still a dinosaur ... we are a different species."

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